Failure to Document COVID-19 Vaccination Status and Offer for Two Residents
Penalty
Summary
Surveyors found that the facility failed to ensure medical records contained documentation that each resident received or was offered COVID-19 vaccination, as required by facility policy. Record review for one resident (R #4) showed an admission date but no documentation in the Electronic Health Record (EHR) that the resident had received or been offered the COVID-19 vaccine. Similarly, record review for another resident (R #5) showed an admission date but no documentation in the EHR that the resident had received or been offered the COVID-19 vaccine. During an interview on 12/05/25 at 1:22 p.m., the DON confirmed that there was no record for either resident indicating receipt of, or an offer of, the COVID-19 vaccination. The deficiency was identified during review of five residents’ records for immunizations, with two residents lacking any documentation of COVID-19 vaccination status or offer of vaccination in their EHRs, despite the facility’s responsibility to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible individuals, and properly document vaccination status.
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